Nursing 275 Exam 4|339 Questions with Verified Answers,100% CORRECT

Nursing 275 Exam 4|339 Questions with Verified Answers CDE - CORRECT ANSWER The nurse meets with a patient who was a victim of sexual assault. Which statements made by the patient indicate recovery? Select all that apply. a. "I try not to think about the night that I was raped." b. "I realize that I am hopeless about trusting others." c. "I feel comfortable hanging out with my male friends." d. "I manage the really dark days by going to a gym class." e. "All of my bruises have healed, and I can wear tank tops again." bcd - CORRECT ANSWER A nurse caring for a patient who was sexually assaulted reports to the primary healthcare provider that the patient has effectively recovered. Which responses by the patient led the nurse to identify the patient's effective recovery? Select all that apply. a. The patient identifies emotions. b. The patient expresses the right to be protected. c. The patient starts interacting with family members. d. The patient expresses anger in a nondestructive way. e. The patient starts interacting verbally and nonverbally. a - CORRECT ANSWER A student nurse interacts with the sexual assault nurse examiner (SANE) during internship. The student nurse asks the SANE to share an experience while caring for victims of sexual assault. Which response given by the SANE is appropriate? a. "I have seen rape victims from 6 months to 90 years old." b. "I noticed that most rapes are impulsive acts of the rapists." c. "I feel that patients get severe injuries when they try to escape." d. "I overlook my feelings toward sexual assault before caring for the patient." b - CORRECT ANSWER Which nursing action has priority for a patient immediately following a reported rape? a. Provide written follow-up instructions. b. Document the debris and dirt on the patient's clothing. c. Give the patient alone time to recover after the incident. d. Give the patient prophylactic analgesics after the incident. abcde - CORRECT ANSWER Arrange the steps of the medical exam of a rape victim based on best practice guidelines. a. Head-to-toe physical assessment b. Genital examination c. Collection of evidence d. Documentation of biological and physical findings e. Treatment, discharge planning, and follow-up care a - CORRECT ANSWER When the nurse finishes addressing a group of college women about rape, the following comments are heard during the discussion period. Which comment calls for additional teaching by the nurse? a. "So if you dress conservatively, your risk of being raped is small." b. "Who would have guessed that most rape victims know the rapist?" c. "It makes sense that rape is a crime of violence, not a crime of sex." d. "I always thought rapes happened at night, but now I know that isn't true." b - CORRECT ANSWER The nurse is providing discharge teaching to a patient who was recently raped. What should the nurse say regarding the psychological effects of the assault? a. "You may feel hyperactive and notice an increased surge of energy." b. "It is normal to experience depression after being sexually assaulted." c. "People often report the need to be social after a sexual assault incident." d. "Let the healthcare provider know immediately if you feel scared or worried." ade - CORRECT ANSWER Which statement is true regarding the nursing care of a forensic patient? Select all that apply. a. A victim of a sexual assault meets the criteria of a forensic patient. b. Nurses should pose questions asking "why" certain events occurred. c. All sexual assault victims require a complete suicide assessment interview initially. d. Asking about possible suicidal ideations may be an appropriate interview question. e. Sexual assault nurse examiners (SANE) are trained especially to meet the needs of a sexual assault victim. revictimization - CORRECT ANSWER The nurse is explaining the forensic exam to a patient who was just sexually assaulted. The patient does not want to be examined and says, "I feel like my body just keeps getting violated more and more." Which is the best term used to describe this feeling? d - CORRECT ANSWER The nurse at a university health center leads a dialogue with female freshmen about rape and sexual assault. One student says, "If I avoid strangers or situations where I am alone outside at night, I'll be safe from sexual attacks." Choose the nurse's best response. a. "Your plan is not adequate. You could still be raped or sexually assaulted." b. "I am glad you have this excellent safety plan. Would others like to comment?" c. "It's better to walk with someone or call security when you enter or leave a building." d. "Sexual assaults are more often perpetrated by acquaintances. Let's discuss ways to prevent that." d - CORRECT ANSWER A woman was found confused and disoriented after being abducted and raped at gunpoint by an unknown assailant. The emergency department nurse makes these observations about the woman: talking rapidly in disjointed phrases, unable to concentrate, indecisive when asked to make simple decisions. What is the woman's level of anxiety? a. Weak b. Mild c. Moderate d. Severe b - CORRECT ANSWER After an abduction and rape at gunpoint by an unknown assailant, which assessment finding best indicates that a patient is in the acute phase of the rape-trauma syndrome? a. Decreased motor activity b. Confusion and disbelief c. Flashbacks and dreams d. Fears and phobias b - CORRECT ANSWER A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The patient says, "I shouldn't have been there alone. I knew it was a dangerous area." What is the patient's present coping strategy? a. Projection b. Self-blame c. Suppression d. Rationalization b - CORRECT ANSWER An emergency department nurse prepares to assist with evidence collection for a sexual assault victim. Prior to photographs and pelvic examination, what documentation is important? a. The patient's vital signs b. Consent signed by the patient c. Supervision and credentials of the examiner d. Storage location of the patient's personal effects b - CORRECT ANSWER A nurse in the emergency department assesses an unresponsive victim of rape. The victim's friend reports, "That guy gave her salty water before he raped her." Which question is most important for the nurse to ask of the victim's friend? a. "Does the victim have any kidney disease?" b. "Has the victim consumed any alcohol?" c. "What time was she given salty water?" d. "Did you witness the rape?" a - CORRECT ANSWER A rape victim says to the nurse, "I always try to be so careful. I know I should not have walked to my car alone. Was this attack my fault?" Which communication by the nurse is most therapeutic? a. Support the victim to separate issues of vulnerability from blame. b. Emphasize the importance of using a buddy system in public places. c. Reassure the victim that the outcome of the situation will be positive. d. Pose questions about the rape and help the patient explore why it happened. d - CORRECT ANSWER A rape victim tells the nurse, "I should not have been out on the street alone." Select the nurse's most therapeutic response. a. "Rape can happen anywhere." b. "Blaming yourself increases your anxiety and discomfort." c. "You are right. You should not have been alone on the street at night." d. "You feel as though this would not have happened if you had not been alone." d - CORRECT ANSWER The nursing diagnosis Rape-trauma syndrome applies to a rape victim in the emergency department. Select the most appropriate outcome to achieve before discharging the patient. a. The memory of the rape will be less vivid and less frightening. b. The patient is able to describe feelings of safety and relaxation. c. Symptoms of pain, discomfort, and anxiety are no longer present. d. The patient agrees to a follow-up appointment with a rape victim advocate. c - CORRECT ANSWER A rape victim visited a rape crisis counselor weekly for 8 weeks. At the end of this counseling period, which comment by the victim best demonstrates that reorganization was successful and the victim is now in recovery? a. "I have a rash on my buttocks. It itches all the time." b. "Now I know what I did that triggered the attack on me." c. "I'm sleeping better although I still have an occasional nightmare." d. "I have lost 8 pounds since the attack, but I needed to lose some weight." b - CORRECT ANSWER A nurse interviews a 17-year-old male victim of sexual assault. The victim is reluctant to talk about the experience. Which comment should the nurse offer to this victim? a. "Male victims of sexual assault are usually better equipped than women to deal with the emotional pain that occurs." b. "Male victims of sexual assault often experience physical injuries and are assaulted by more than one person." c. "Do you have any male friends who have also been victims of sexual assault?" d. "Why do you think you became a victim of sexual assault?" a - CORRECT ANSWER A nurse works at rape telephone hotline. Communication with potential victims should focus on a. explaining immediate steps victims should take. b. providing callers with a sympathetic listener. c. obtaining information for law enforcement. d. arranging counseling. d - CORRECT ANSWER A nurse cares for a rape victim who was given a drink that contained flunitrazepam by an assailant. Which intervention has priority? Monitoring for a. coma. b. seizures. c. hypotonia. d. respiratory depression. d - CORRECT ANSWER Before a victim of sexual assault is discharged from the emergency department, the nurse should a. notify the victim's family to provide emotional support. b. offer to stay with the patient until stability is regained. c. advise the patient to try not to think about the assault. d. provide referral information verbally and in writing. a - CORRECT ANSWER A victim of a sexual assault who sits in the emergency department is rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of which stage of rape-trauma syndrome? a. The acute phase reaction b. The long-term phase c. A delayed reaction d. The angry stage b - CORRECT ANSWER A victim of a sexual assault comes to the hospital for treatment but abruptly decides to decline treatment and leaves the facility. While respecting the person's rights, the nurse should a. say, "You may not leave until you receive prophylactic treatment for sexually transmitted diseases." b. provide written information about physical and emotional reactions the person may experience. c. explain the need and importance of infectious disease and pregnancy tests. d. give verbal information about legal resources in the community. b - CORRECT ANSWER An unconscious teenager is treated in the emergency department. The teenager's friends suspect the teenager was drugged and raped at a party. Priority action by the nurse should focus on a. preserving rape evidence. b. maintaining physiological stability. c. determining what drugs were ingested. d. obtaining a description of the rape from a friend. a - CORRECT ANSWER A victim of a violent rape was treated in the emergency department. As discharge preparation begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no reason to go on." Select the nurse's most appropriate response. a. "Are you thinking of harming yourself?" b. "It will take time, but you will feel the same as before the attack." c. "Your friends will understand when you explain it was not your fault." d. "You will be able to find meaning from this experience as time goes on." acd - CORRECT ANSWER When an emergency department nurse teaches a victim of rape-trauma syndrome about reactions that may occur during the long-term phase, which symptoms should be included? (Select all that apply.) a. Development of fears and phobias b. Decreased motor activity c. Feelings of numbness d. Flashbacks, dreams e. Syncopal episodes abc - CORRECT ANSWER A patient was abducted and raped at gunpoint by an unknown assailant. Which nursing interventions are appropriate while caring for the patient in the emergency department? (Select all that apply.) a. Allow the patient to talk at a comfortable pace. b. Place the patient in a private room with a caregiver. c. Pose questions in nonjudgmental, empathetic ways. d. Invite the patient's family members to the examination room. e. Put an arm around the patient to demonstrate support and compassion. abc - CORRECT ANSWER An emergency department nurse prepares to assist with examination of a sexual assault victim. What equipment will be needed to collect and document forensic evidence? (Select all that apply.) a. Camera b. Body map c. DNA swabs d. Pulse oximeter e. Sphygmomanometer ade - CORRECT ANSWER Which aspects of assessment have priority when a nurse interviews a rape victim in an acute setting? (Select all that apply.) a. Coping mechanisms the patient is using b. The patient's previous sexual experiences c. The patient's history of sexually transmitted diseases d. Signs and symptoms of emotional and physical trauma e. Adequacy and availability of the patient's support system bd - CORRECT ANSWER A rape victim tells the emergency nurse, "I feel so dirty. Help me take a shower before I get examined." The nurse should (Select all that apply.) a. arrange for the victim to shower. b. explain that bathing destroys evidence. c. give the victim a basin of water and towels. d. offer the victim a shower after evidence is collected. e. explain that bathing facilities are not available in the emergency department. acd - CORRECT ANSWER Which scenarios describe completed rape? (Select all that apply.) a. A husband forces vaginal sex when he comes home intoxicated from a party. The wife objects. b. A woman's lover pleads with her to have oral sex. She gives in but later regrets the decision. c. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant. d. A dentist gives anesthesia for a procedure and then has intercourse with the unconscious patient. e. A perpetrator grabs a potential victim, tears off most of her clothing, and fondles her breasts before she escapes. A patient comes to the crisis clinic after an unexpected job termination. The patient paces around the room sobbing, cringes when approached, and responds to questions with only shrugs or monosyllables. Choose the nurse's best initial comment to this patient. blems." - CORRECT ANSWER "I see you are feeling upset. I'm going to stay and talk with you to help you feel better." A crisis exists for this patient. The two primary thrusts of crisis intervention are to provide for the safety of the individual and use anxiety-reduction techniques to facilitate use of inner resources. The nurse offers therapeutic presence, which provides caring, ongoing observation relative to the patient's safety, and interpersonal reassurance. A patient being seen in the clinic for superficial cuts on both wrists is pacing and sobbing. After a few minutes, the patient is calmer. The nurse attempts to determine the patient's perception of the precipitating event by asking: - CORRECT ANSWER "What was happening just before you started to feel this way?" A clear definition of the immediate problem provides the best opportunity to find a solution. Asking about recent upsetting events permits assessment of the precipitating event. "Why" questions are non-therapeutic. A patient comes to the crisis center saying, "I'm in a terrible situation. I don't know what to do." The triage nurse can initially assume that the patient is: - CORRECT ANSWER anxious and fearful. Individuals in crisis are universally anxious. They are often frightened and may be mildly confused. Perceptions are often narrowed with anxiety. An adolescent comes to the crisis clinic and reports sexual abuse by an uncle. The adolescent told both parents about the uncle's behavior, but the parents did not believe the adolescent. What type of crisis exists? - CORRECT ANSWER Situational (Adventitious) Situation crisis arises from events that are extraordinary, external rather than internal and often unanticipated. An adventitious crisis is a crisis of disaster that is not a part of everyday life. It is unplanned or accidental. Adventitious crises include natural disasters, national disasters, and crimes of violence. Sexual molestation falls within this classification. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. Situational crisis arises from an external source such as a job loss, divorce, or other loss affecting self-concept or self-esteem. "Organic" is not a type of crisis. While conducting the initial interview with a patient in crisis, the nurse should: - CORRECT ANSWER speak in short, concise sentences. Severe anxiety narrows perceptions and concentration. By speaking in short concise sentences, the nurse enables the patient to grasp what is being said. Conveying urgency will increase the patient's anxiety. Letting the patient know who controls the interview or stating that time is limited is non-therapeutic. An adult seeks counseling after the spouse was murdered. The adult angrily says, "I hate the beast that did this. It has ruined my life. During the trial, I don't know what I'll do if the jury doesn't return a guilty verdict." What is the nurse's highest priority response? - CORRECT ANSWER "Are you having thoughts of hurting yourself or others?" The highest nursing priority is safety. The nurse should assess suicidal and homicidal potential. The distracters are options, but the highest priority is safety. Six months ago, a woman had a prophylactic double mastectomy because of a family history of breast cancer. One week ago, this woman learned her husband was involved in an extramarital affair. The woman tearfully says to the nurse, "What else can happen?" What type of crisis is this person experiencing? - CORRECT ANSWER Situational A situational crisis arises from an external source and involves a loss of self-concept or self-esteem. An adventitious crisis is a crisis of disaster, such as a natural disaster or crime of violence. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. No classification of recurring crisis exists. A woman said, "I can't take anymore! Last year my husband had an affair, and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." What is the nurse's priority assessment? - CORRECT ANSWER Clarify what the patient means by "I can't take anymore." During crisis intervention, the priority concern is patient safety. This question helps assess personal coping skills. The other options are incorrect because the focus of crisis intervention is on the event that occurred immediately before the patient sought help. Six months ago, a woman had a prophylactic double mastectomy because of a family history of breast cancer. One week ago, this woman learned her husband was involved in an extramarital affair. The woman tearfully, "What else can happen?" If the woman's immediate family is unable to provide sufficient support, the nurse should: - CORRECT ANSWER ask what other relatives or friends are available for support. The assessment of situational supports should continue. Even though the patient's nuclear family may not be supportive, other situational supports may be available. If they are adequate, admission to an inpatient unit will be unnecessary. Psychotherapy is not appropriate for crisis intervention. Advice is usually non-therapeutic. A woman says, "I can't take anymore. Last year my husband had an affair, and now we do not communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college and moving in with her boyfriend." Which issue should the nurse focus on during crisis intervention? - CORRECT ANSWER Coping with the reaction to the daughter's events The focus of crisis intervention is on the most recent problem: "the straw that broke the camel's back." The patient had coped with the breast lesion, the husband's infidelity, and the disordered communication. Disequilibrium occurred only with the introduction of the daughter leaving college and moving. A patient who is visiting the crisis clinic for the first time asks, "How long will I be coming here?" The nurse's reply should consider that the usual duration of crisis intervention is: - CORRECT ANSWER 4 to 6(8) weeks. The disorganization associated with crisis is so distressing that it usually cannot be tolerated for more than 4 to 8 weeks. If it is not resolved by that time, the individual usually adopts dysfunctional behaviors that reduce anxiety without solving the problem. Crisis intervention can shorten the duration. A student falsely accused a college professor of sexual intimidation. The professor tells the nurse, "I cannot teach nor do any research. My mind is totally preoccupied with these false accusations." What is the priority nursing diagnosis? - CORRECT ANSWER Ineffective coping (role performance) related to distress from false accusations This nursing diagnosis is the priority because it reflects the consequences of the precipitating event associated with the professor's crisis. There is no evidence of denial. Deficient knowledge may apply, but it is not the priority. Data are not present to diagnose impaired social interaction. Which communication technique will the nurse use more in crisis intervention than traditional counseling? - CORRECT ANSWER Giving direction The nurse working in crisis intervention must be creative and flexible in looking at the patient's situation and suggesting possible solutions to the patient. Giving direction is part of the active role a crisis intervention therapist takes. The other options are used equally in crisis intervention and traditional counseling roles. Which situation demonstrates use of primary care related to crisis intervention? - CORRECT ANSWER Teaching stress reduction techniques to a first-year college student Primary care-related crisis intervention promotes mental health and reduces mental illness. The incorrect options are examples of secondary or tertiary care A victim of spousal violence comes to the crisis center seeking help. Crisis intervention strategies the nurse uses will focus on: - CORRECT ANSWER supporting emotional security and reestablishing equilibrium. Strategies of crisis intervention address the immediate cause of the crisis and restoration of emotional security and equilibrium. The goal is to return the individual to the pre-crisis level of function. Crisis intervention is, by definition, short term. The correct response is the most global answer. Promoting growth is a focus of long-term therapy. Providing legal assistance might or might not be applicable. After celebrating the fortieth birthday, an individual becomes concerned with the loss of youthful appearance. What type of crisis has occurred? - CORRECT ANSWER Maturational Maturational crises occur when a person arrives at a new stage of development and finds that old coping styles are ineffective but has not yet developed new strategies. Situational crises arise from sources external to the individual, such as divorce and job loss. There is no classification called reactive. Adventitious crises occur when disasters, such as natural disasters (e.g., floods, hurricanes), war, or violent crimes, disrupt coping. Which scenario is an example of an adventitious crisis? - CORRECT ANSWER A riot at a rock concert The rock concert riot is unplanned, accidental, violent, and not a part of everyday life. The incorrect options are examples of situational or maturational crises. Which agency provides coordination in the event of a terrorist attack? - CORRECT ANSWER National Incident Management System (NIMS) The National Incident Management System (NIMS) provides a systematic approach to guide departments and agencies at all levels of government, nongovernmental organizations, and the private sector during disaster situations. During the initial interview at the crisis center, a patient says, "I've been served with divorce papers. I'm so upset and anxious that I can't think clearly." Which comment should the nurse use to assess personal coping skills? - CORRECT ANSWER "In the past, how have you handled difficult or stressful situations?" The correct answer is the only option that assesses coping skills. The incorrect options are concerned with self-esteem, ask the patient to decide on treatment at a time when he or she "cannot think clearly," and seek to explore issues tangential to the crisis. An adult has cared for a debilitated parent for 10 years. The parent's condition recently declined, and the health care provider recommended placement in a skilled nursing facility. The adult says, "I've always been able to care for my parents. Nursing home placement goes against everything I believe." Successful resolution of this person's crisis will most closely relate to: - CORRECT ANSWER resolving the feelings associated with the threat to the person's self-concept. The patient's crisis clearly relates to a loss of (or threatened change in) self-concept. Her capacity to care for her parents, regardless of the deteriorating condition, has been challenged. Crisis resolution will involve coming to terms with the feelings associated with this loss. Identifying situational supports is relevant, but less so than coming to terms with the threat to self-concept. Reliance on lessons from role models can be helpful but not the primary factor associated with resolution in this case. Automatic relief behaviors will not be helpful. Automatic relief behaviors are part of the fourth phase of crisis. The principle most useful to a nurse planning crisis intervention for any patient is that the patient: - CORRECT ANSWER is experiencing a state of disequilibrium. Disequilibrium is the only answer universally true for all patients in crisis. A crisis represents a struggle for equilibrium when problems seem unsolvable. Crisis does not reflect mental illness. Potential for self-violence or other-directed violence may or may not be a factor in crisis. A nurse assesses a patient in crisis. Select the most appropriate question for the nurse to ask to assess this patient's situational support. - CORRECT ANSWER "Who can be helpful to you during this time?" Only the answer focuses on situational support. The incorrect options focus on the patient's perception of the precipitating event. An adult comes to the crisis clinic after termination from a job of 15 years. The patient says, "I don't know what to do. How can I get another job? Who will pay the bills? How will I feed my family?" Which nursing diagnosis applies? - CORRECT ANSWER Powerlessness The patient describes feelings of lack of control over life events. No direct mention is made of hopelessness or chronic low self-esteem. The patient's thought processes are not altered at this point. A troubled adolescent pulled out a gun in a school cafeteria, fatally shooting three people and injuring many others. Hundreds of parents come to the school after hearing news reports. After police arrest the shooter, which action should occur next? - CORRECT ANSWER Designate zones according to the alphabet and direct students to the zones based on their surnames to facilitate reuniting them with their parents Chaos is likely among students and desperate parents. A directive approach is best. Once the scene is secure, creative solutions are needed. Creating zones by letters of the alphabet will assist anxious parents and their children to unite. Preventing parents from uniting with their children will further incite the situation. At the last contracted visit in the crisis intervention clinic, an adult says, "I've emerged from this a stronger person. You helped me get my life back in balance." The nurse responds, "I think we should have two more sessions to explore why your reactions were so intense." Which analysis applies? - CORRECT ANSWER The nurse is having difficulty terminating the relationship. The nurse's remark is clearly an invitation to work on other problems and prolong contact with the patient. The focus of crisis intervention is the problem that precipitated the crisis, not other issues. The scenario does not describe transference. The patient shows no need for continuing support. The scenario does not describe dependency needs. Which health care worker should be referred for critical incident stress debriefing? - CORRECT ANSWER An emergency medical technician (EMT) who treated victims of a car bombing at a mall Although each of the individuals mentioned experiencing job-related stress on a daily basis, the person most in need of critical incident stress debriefing is the EMT, who experienced an adventitious crisis event by responding to a bombing and provided care to trauma victims. A nurse driving home after work comes upon a serious automobile accident. The driver gets out of the car with no apparent physical injuries. Which assessment findings would the nurse expect from the driver immediately after this event? Select all that apply. - CORRECT ANSWER Difficulty using a cell phone Rapid speech Trembling Immediate responses to crisis commonly include shock, numbness, denial, confusion, disorganization, difficulty with decision making, and physical symptoms such as nausea, vomiting, tremors, profuse sweating, and dizziness associated with anxiety. Incontinence and long-term memory losses would not be expected. A team of nurses report to the community after a category 5 hurricane devastates many homes and businesses. The nurses provide emergency supplies of insulin to persons with diabetes and help transfer patients in skilled nursing facilities to sites that have electrical power. Which aspects of disaster management have these nurses fulfilled? Select all that apply. - CORRECT ANSWER Mitigation Response This community has experienced a catastrophic event. There are five phases of the disaster management continuum. The nurses' activities applied to mitigation (attempts to limit a disaster's impact on human health and community function) and response (actual implementation of a disaster plan). Preparedness occurs before an event. Recovery actions focus on stabilizing the community and returning it to its previous status. Evaluation of the response efforts apply to the future. b - CORRECT ANSWER A patient who has been diagnosed with dissociative identity disorder asks, "What exactly are 'alters'? My health care provider told me I have several of them." Which statement by the patient illustrates that the education provided has been effective? a. "Alters are never aware of each other." b. "Alters are separate personalities that take over during stress." c. "Alters are based in mysticism and religiosity, such as demons." d. "Alters are just like me, but they have no memory of the trauma I went through." d - CORRECT ANSWER A child reared in a minority culture is at greatest risk for: a. Bullying b. Homicidal thoughts c. Eating- and sleep-related disorders d. Traumatic experiences in early childhood b - CORRECT ANSWER What information should the nurse give to the family of a patient who has had a dissociative episode? a. Brief periods of psychotic behavior may occur b. Dissociation is a method for coping with severe stress c. Dissociation suggests the possibility of early dementia d. Ways to intervene to prevent self-mutilation and suicide attempts bdef - CORRECT ANSWER The nurse is assessing a young child for posttraumatic stress disorder (PTSD). What does the nurse include in the assessment? Select all that apply. a. Bowel habits b. Motor function c. Blood pressure d. Speech patterns e. General appearance f. Characteristics of play c - CORRECT ANSWER When caring for a child with posttraumatic stress disorder, which intervention should the nurse include in the patient plan of care? a. Provide changeable environment. b. Help patient learn positive avoidance. c. Reduce stimulation of traumatic memories. d. Promote arousal to build tolerance to stress. a - CORRECT ANSWER Which assessment tool does the nurse use while assessing a patient with dissociative identity disorder? a. Somatoform questionnaire b. Child dissociative checklist c. Child sexual behavior inventory d. Posttraumatic stress disorder screening a - CORRECT ANSWER A patient who is a victim of sexual assault has insomnia, reduced concentration, anxiety, and recurring thoughts of the event. Which medication does the nurse anticipate being prescribed for the patient? a. Clonidine b. Citalopram c. Propranolol d. Desipramine b - CORRECT ANSWER A nurse works with a patient diagnosed with posttraumatic stress disorder (PTSD) who has frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be included in the plan of care? a. Trigger flashbacks intentionally in order to help the patient learn to cope with them. b. Explain that the physical symptoms are related to the psychological state. c. Encourage repression of memories associated with the traumatic event. d. Support "numbing" as a temporary way to manage intolerable feelings. d - CORRECT ANSWER Four teenagers died in an automobile accident. One week later, which behavior by the parents of these teenagers most clearly demonstrates resilience? The parents who a. visit their teenager's grave daily. b. return immediately to employment. c. discuss the accident within the family only. d. create a scholarship fund at their child's high school b - CORRECT ANSWER After the sudden death of his wife, a man says, "I can't live without her ... she was my whole life." Select the nurse's most therapeutic reply. a. "Each day will get a little better." b. "Her death is a terrible loss for you." c. "It's important to recognize that she is no longer suffering." d. "Your friends will help you cope with this change in your life." c - CORRECT ANSWER A woman just received notification that her husband died. She approaches the nurse who cared for him during his last hours and says angrily, "If you had given him your undivided attention, he would still be alive." How should the nurse analyze this behavior? a. The comment suggests potential allegations of malpractice. b. In some cultures, grief is expressed solely through anger. c. Anger is an expected emotion in an adjustment disorder. d. The patient had ambivalent feelings about her husband. a - CORRECT ANSWER A wife received news that her husband died of heart failure and called her family to come to the hospital. She angrily tells the nurse who cared for him, "He would still be alive if you had given him your undivided attention." Select the nurse's best intervention. a. Say to the wife, "I understand you are feeling upset. I will stay with you until your family comes." b. Say to the wife, "Your husband's heart was so severely damaged that it could no longer pump." c. Say to the wife, "I will call the health care provider to discuss this matter with you." d. Hold the wife's hand in silence until the family arrives. d - CORRECT ANSWER A child drowned while swimming in a local lake 2 years ago. Which behavior indicates the child's parents have adapted to their loss? The parents a. visit their child's grave daily. b. maintain their child's room as the child left it 2 years ago. c. keep a place set for the dead child at the family dinner table. d. throw flowers on the lake at each anniversary date of the accident. d - CORRECT ANSWER A store clerk was killed during a robbery 2 weeks ago. His widow, who has a long history of schizoaffective disorder, cries spontaneously when talking about his death. Select the nurse's most therapeutic response. a. "Are you taking your medications the way they are prescribed?" b. "This loss is harder to accept because of your mental illness. Do you think you should be hospitalized?" c. "I'm worried about how much you are crying. Your grief over your husband's death has gone on too long." d. "The unexpected death of your husband is very painful. I'm glad you are able to talk about your feelings." a - CORRECT ANSWER Which scenario demonstrates a dissociative fugue? a. After being caught in an extramarital affair, a man disappeared but then reappeared months later with no memory of what occurred while he was missing. b. A man is extremely anxious about his problems and sometimes experiences dazed periods of several minutes passing without conscious awareness of them. c. A woman finds unfamiliar clothes in her closet, is recognized when she goes to new restaurants, and complains of "blackouts" despite not drinking. d. A woman reports that when she feels tired or stressed, it seems like her body is not real and is somehow growing smaller. a - CORRECT ANSWER The nurse who is counseling a patient with dissociative identity disorder should understand that the assessment of highest priority is a. risk for self-harm. b. cognitive function. c. memory impairment. d. condition of self-esteem. c - CORRECT ANSWER A patient states, "I feel detached and weird all the time. It is as though I am looking at life through a cloudy window. Everything seems unreal. It really messes up things at work and school." This scenario is most suggestive of which health problem? a. Acute stress disorder b. Dissociative amnesia c. Depersonalization disorder d. Disinhibited social engagement disorder b - CORRECT ANSWER The unlicensed assistive personnel (UAP) says to the nurse, "That patient with amnesia looks fine, but when I talk to her, she seems vague. What should I be doing for her?" Select the nurse's best reply. a. "Spend as much time with her as you can and ask questions about her life." b. "Use short, simple sentences and keep the environment calm and protective." c. "Provide more information about her past to reduce the mysteries that are causing anxiety." d. "Structure her time with activities to keep her busy, stimulated, and regaining concentration." b - CORRECT ANSWER A patient diagnosed with depersonalization disorder tells the nurse, "It's starting again. I feel as though I'm going to float away." Which intervention would be most appropriate at this point? a. Notify the health care provider of this change in the patient's behavior. b. Engage the patient in a physical activity such as exercise. c. Isolate the patient until the sensation has diminished. d. Administer a prn dose of antianxiety medication. c - CORRECT ANSWER A person runs from a crowded nightclub after a pyrotechnics show causes the building to catch fire. Which division of the autonomic nervous system will be stimulated in response to this experience? a. Limbic system b. Peripheral nervous system c. Sympathetic nervous system d. Parasympathetic nervous system b - CORRECT ANSWER The gas pedal on a person's car became stuck on a busy interstate highway, causing the car to accelerate rapidly. For 20 minutes, the car was very difficult to control. In the months after this experience, afterward, which assessment finding would the nurse expect? a. Weight gain b. Flashbacks c. Headache d. Diuresis c - CORRECT ANSWER A soldier returns to the United States from active duty in a combat zone. The soldier is diagnosed with PTSD. The nurse's highest priority is to screen this soldier for a. bipolar disorder. b. schizophrenia. c. depression. d. dementia. b - CORRECT ANSWER Two weeks ago, a soldier returned to the United States from active duty in a combat zone. The soldier was diagnosed with PTSD. Which comment by the soldier requires the nurse's immediate attention? a. "It's good to be home. I missed my home, family, and friends." b. "I saw my best friend get killed by a roadside bomb. I don't understand why it wasn't me." c. "Sometimes I think I hear bombs exploding, but it's just the noise of traffic in my hometown." d. "I want to continue my education, but I'm not sure how I will fit in with other college students." b - CORRECT ANSWER A soldier returned home from active duty in a combat zone and was diagnosed with PTSD. The soldier says, "If there's a loud noise at night, I get under my bed because I think we're getting bombed." What type of experience has the soldier described? a. Illusion b. Flashback c. Nightmare d. Auditory hallucination d - CORRECT ANSWER A soldier returned 3 months ago from a combat zone and was diagnosed with PTSD. Which social event would be most disturbing for this soldier? a. Halloween festival with neighborhood children b. Singing carols around a Christmas tree c. A family outing to the seashore d. Fireworks display on July 4th b - CORRECT ANSWER Which comment by the parents of young children best demonstrates support of development of resilience and effective stress management? a. "Our children will be stronger if they make their own decisions." b. "We spend daily family time talking about experiences and feelings." c. "We use three different babysitters. All of them have college degrees." d. "Our parenting strategies are different from those our own parents used." a - CORRECT ANSWER A soldier in a combat zone tells the nurse, "I saw a child get blown up over a year ago, and I still keep seeing bits of flesh everywhere. I see something red, and the visions race back to my mind." Which phenomenon associated with PTSD is the soldier describing? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis c - CORRECT ANSWER A soldier who served in a combat zone returned to the United States. The soldier's spouse complains to the nurse, "We had planned to start a family, but now he won't talk about it. He won't even look at children." The spouse is describing which symptom associated with PTSD? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis d - CORRECT ANSWER A soldier returned home last year after deployment to a war zone. The soldier's spouse complains, "We were going to start a family, but now he won't talk about it. He will not look at children. I wonder if we're going to make it as a couple." Select the nurse's best response. a. "Posttraumatic stress disorder (PTSD) often changes a person's sexual functioning." b. "I encourage you to continue to participate in social activities where children are present." c. "Have you talked with your spouse about these reactions? Sometimes we just need to confront behavior." d. "Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support." a - CORRECT ANSWER Which assessment finding best supports dissociative fugue? The patient states a. "I cannot recall why I'm living in this town." b. "I feel as if I'm living in a fuzzy dream state." c. "I feel like different parts of my body are at war." d. "I feel very anxious and worried about my problems." a - CORRECT ANSWER After major reconstructive surgery, a patient's wounds dehisced. Extensive wound care was required for 6 months, causing the patient to miss work and social activities. Which physiological response would be expected for this patient? a. Vital signs return to normal. b. Release of endogenous opioids would cease. c. Pulse and blood pressure readings are elevated. d. Psychomotor abilities of the right brain become limited. a - CORRECT ANSWER Relaxation techniques help patients who have experienced major traumas because they a. engage the parasympathetic nervous system. b. increase sympathetic stimulation. c. increase the metabolic rate. d. release hormones. d - CORRECT ANSWER Select the correct etiology to complete this nursing diagnosis for a patient diagnosed with dissociative identity disorder. Disturbed personal identity related to a. obsessive fears of harming self or others. b. poor impulse control and lack of self-confidence. c. depressed mood secondary to nightmares and intrusive thoughts. d. cognitive distortions associated with unresolved childhood abuse issues. abd - CORRECT ANSWER A young adult says, "I was sexually abused by my older brother. During those assaults, I went somewhere else in my mind. I don't remember the details. Now, I often feel numb or unreal in romantic relationships, so I just avoid them." Which disorders should the nurse suspect based on this history? (Select all that apply.) a. Acute stress disorder b. Depersonalization disorder c. Generalized anxiety disorder d. PTSD e. Reactive attachment disorder f. Disinhibited social engagement disorder abce - CORRECT ANSWER A 10-year-old child was placed in a foster home after being removed from parental contact because of abuse. The child has apprehension, tremulousness, and impaired concentration. The foster parent also reports the child has an upset stomach, urinates frequently, and does not understand what has happened. What helpful measures should the nurse suggest to the foster parents? The nurse should recommend (Select all that apply) a. conveying empathy and acknowledging the child's distress. b. explaining and reinforcing reality to avoid distortions. c. using a calm manner and low, comforting voice. d. avoiding repetition in what is said to the child. e. staying with the child until the anxiety decreases. f. minimizing opportunities for exercise and play. abcef - CORRECT ANSWER The nurse interviewing a patient with suspected PTSD should be alert to findings indicating the patient (Select all that apply) a. avoids people and places that arouse painful memories. b. experiences flashbacks or re-experiences the trauma. c. experiences symptoms suggestive of a heart attack. d. feels compelled to repeat selected ritualistic behaviors. e. demonstrates hypervigilance or distrusts others. f. feels detached, estranged, or empty inside. cde - CORRECT ANSWER Which experiences are most likely to precipitate PTSD? (Select all that apply). a. A young adult bungee jumped from a bridge with a best friend. b. An 8-year-old child watched an R-rated movie with both parents. c. An adolescent was kidnapped and held for 2 years in the home of a sexual predator. d. A passenger was in a bus that overturned on a sharp curve and tumbled down an embankment. e. An adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks b - CORRECT ANSWER A nurse prepares the plan of care for a school-age child diagnosed with reactive attachment disorder. Which initial outcome should be the focus of the nurse's intervention? The child will: a. Decrease impulsive behavior b. Express feelings through journaling c. Verbally recount traumatic experiences d. Correctly identify the date, time, and place abd - CORRECT ANSWER The nurse is planning care for a patient diagnosed with a dissociative disorder. Which intervention is directed primarily towards minimizing the patient's anxiety level? Select all that apply. a. Provide a simple, predictable daily routine. b. Teach and reinforce relaxation and deep breathing techniques. c. Work with the patient and involved parties to reestablish relationships. d. Allow the patient to progress at his or her own pace as memories are recovered. e. Provide support through empathetic listening during disclosure of painful experiences. c - CORRECT ANSWER A nurse is developing a plan of care for a patient with dissociative amnesia. Which strategies should the nurse include in the plan? a. Allow the patient to rest. b. Ask the patient to recollect past events. c. Instruct the patient on grounding techniques. d. Ask the family member to make routine decisions. a - CORRECT ANSWER A nurse conducts an initial interview with a veteran of two tours in the war with Iraq. The veteran says, "The war was years ago, but I still remember my friends who were killed. I don't know why I lived and they died." What is the nurse's priority response? a. "Are you having any thoughts of harming yourself?" b. "It's important to think about how good your life is now." c. "Are you saying you have some guilt about being a survivor?" d. "The outcomes of war are tragic and stay with us for many years." ace - CORRECT ANSWER A nurse is assessing a child who has witnessed violence at home. What should the nurse document when completing an admission genogram of the child? Select all that apply. a. Relationships b. Investigations c. Family history d. Laboratory testing e. Family composition b - CORRECT ANSWER A nurse is performing an assessment of a child diagnosed with disinhibited social engagement disorder. Which behavior should the nurse expect to find in the child? a. The child throws stones at strangers. b. The child willingly goes with a stranger. c. The child cries when touched by a stranger. d. The child hides when a stranger approaches abdc - CORRECT ANSWER A nurse is caring for a child who needs treatment for mental trauma. Place the stages of the staged treatment protocol in the correct order. a. Provide safety. b. Reduce arousal. c. Nurture self-awareness. d. Teach coping skills. b - CORRECT ANSWER The nurse is caring for a patient with dissociative amnesia disorder. The patient gets extremely aggressive due to anxiety and causes physical harm to him or herself and to others. Which nursing intervention does the nurse follow to reduce anxiety and aggression in the patient? a. The nurse lets the patient make decisions on major issues. b. The nurse frequently observes the patient by visiting the patient's room. c. The nurse reminds the patient about the happy moments of the patient's life. d. The nurse prepares a schedule and instructs the patient to follow it regularly. d - CORRECT ANSWER Empathetic listening is therapeutic because it focuses on: a. Reducing anxiety b. Encouraging resilience c. Enhancing self-esteem d. Lessening feelings of isolation abce - CORRECT ANSWER What symptoms are included in adjustment disorder? Select all that apply. a. Guilt b. Anger c. Depression d. Overachieving e. Social withdrawal c - CORRECT ANSWER According to attachment theory, relationship disorders are related to trauma associated with: a. Culture or religion b. Siblings or strangers c. Caregivers or parents d. Insufficient food or shelter c - CORRECT ANSWER A nurse observes that a child is withdrawn from her parents and does not interact much with them. On inquiry, the nurse finds that the child has been a victim of domestic violence and does not interact with anybody. Which clinical condition is the child likely to have? a. Separation anxiety b. Developmental delays c. Reactive attachment disorder d. Disinhibited social engagement behavior c - CORRECT ANSWER A nurse is caring for an adult patient who has trauma-related disorder. The patient reports to the nurse that he has started using relaxation techniques and is sleeping better. How should the nurse interpret this behavior? a. The patient is feeling nervous. b. The patient is feeling less confident. c. The patient is able to manage anxiety. d. The patient has improved self-esteem. a - CORRECT ANSWER When discussing the symptoms of posttraumatic stress disorder (PTSD), the nurse correctly states: a. "The symptoms can occur almost immediately or can take years to manifest." b. "PTSD causes agitation and hypervigilance, but rarely chronic depression." c. "PTSD is an emotional response that does not cause significant changes in brain chemistry." d. "When experiencing a flashback, the patient generally experiences a slowing of responses." c - CORRECT ANSWER A patient with dissociative identity disorder reports an increased awareness of his or her surroundings and a reduction in dissociative episodes. Which instruction provided by the nurse while teaching the grounding techniques helped the patient to alleviate symptoms? a. "Have a positive insight." b. "Write your feelings in a diary." c. "Hold an ice cube in your hand." d. "Sit straight and upright in the chair." d - CORRECT ANSWER Which statement about structural dissociation of the personality is true? a. An organic basis exists for this type of disorder. b. Nurses perceive patients with this disorder as easy to care for. c. No known link exists between this disorder and early childhood loss or trauma. d. This disorder results in a split in the personality, causing a lack of integration. bcd - CORRECT ANSWER Which behavior would support a diagnosis of posttraumatic stress disorder (PTSD) in a preschool child? Select all that apply. a. Engages in specific, ritual behaviors b. Frequent displays of irritability and negativity c. Reluctant to engage in previously enjoyed activities d. Expresses concern that "something bad is going to happen" e. Shares that he or she "hears voices when there is no one there" d - CORRECT ANSWER A 35-year-old army combat veteran is being treated for migraines and hypertension. The nurse is particularly interested in the individual's response to which mental health-focused question? a. "Are you worried about anything in particular? b. "Is there any history of suicide in your family?" c. "Have you ever experienced a hallucination?" d. "How would you describe posttraumatic stress disorder?" bce - CORRECT ANSWER A nurse has been caring for a patient with posttraumatic stress disorder. Which patient behaviors indicate an improved ability to cope? Select all that apply. a. The patient has improved eye contact. b. The patient asks for help when required. c. The patient has fewer physical complaints. d. The patient shows improved grooming skills. e. The patient tries to find information about treatment. bcde - CORRECT ANSWER Which child should be assessed for possible posttraumatic stress disorder (PTSD) as a result of exposure to major trauma in his or her life? Select all that apply. a. A 3-year-old whose older sibling was born with both physical and cognitive impairments. b. A 4-year-old who was hospitalized for two months after being injured in an automobile accident. c. An 8-year-old child who has a medical history that includes several broken bones and a dislocated shoulder. d. A 5-year-old child who lives with grandparents since his or her single parent was deployed by the military 10 months ago. e. A 12-year-old who has been in cancer remission for three years since finishing both chemotherapy and radiation treatments. a - CORRECT ANSWER A patient who is a victim of sexual assault has insomnia, reduced concentration, anxiety, and recurring thoughts of the event. Which medication does the nurse anticipate being prescribed for the patient? a. Clonidine b. Citalopram c. Propranolol d. Desipramine Cyclobenzaprine (Amrix, Flexeril) is prescribed for a patient with muscle spasms of the lower back. Appropriate nursing interventions would include which of the following? (Select all that apply.) A. Assessing the heart rate for tachycardia B.Assessing the home environment for patient safety concerns C.Encouraging frequent ambulation D. Providing oral suction for excessive oral secretions E. Providing assistance with activities of daily living such as reading - CORRECT ANSWER A. Assessing the heart rate for tachycardia B.Assessing the home environment for patient safety concerns E. Providing assistance with activities of daily living such as reading Adverse reactions to cyclobenzaprine include drowsiness, dizziness, dry mouth, rash, blurred vision, and tachycardia. Because the medication can cause drowsiness and dizziness, ensuring patient safety must be a priority. The patient may need assistance with reading or other activities requiring visual acuity if blurred vision occurs. Options 3 and 4 are incorrect. Patients who are experiencing back pain often have orders for limited ambulation until muscle spasms have subsided. The patient is scheduled to receive rimabotulinumtoxinB (Myobloc) for treatment of muscle spasticity. Which of the following will the nurse teach the patient to report immediately? A.Fever, aches, or chills B. Difficulty swallowing, ptosis, blurred vision C. Continuous spasms and pain on the affected side D. Moderate levels of muscle weakness on the affected side - CORRECT ANSWER B. Difficulty swallowing, ptosis, blurred vision Dysphagia, ptosis, and blurred vision are all symptoms of possible botulinum toxin B toxicity and must be reported immediately. Options 1, 3, and 4 are incorrect. Fever, aches, and chills are not anticipated side effects. Moderate levels of muscle weakness may occur after the drug is administered, and strengthening exercises may be needed on the affected side. Continuous muscle spasms and pain should not occur because the drug blocks muscle contraction. A patient has purchased capsaicin over-the-counter cream to use for muscle aches and pains. What education is most important to give this patient? A. Apply with a gloved hand only to the site of pain. B. Apply the medication liberally above and below the site of pain. C. Apply to areas of redness and irritation only. D. Apply liberally with a bare hand to the affected limb. - CORRECT ANSWER A. Apply with a gloved hand only to the site of pain. Capsaicin should be applied to the site of pain with a gloved hand to avoid introducing the capsaicin to the eyes or other parts of the body not under treatment. Options 2, 3, and 4 are incorrect. Capsaicin should be applied only to the site of pain and never with the bare hand. It should not be applied to irritated or open skin areas and should be discontinued if irritation occurs. A patient has been prescribed clonazepam (Klonopin) for muscle spasms and stiffness secondary to an automobile accident. While the patient is taking this drug, what is the nurse's primary concern? A. Monitoring hepatic laboratory work B. Encouraging fluid intake to prevent dehydration C. Assessing for drowsiness and implementing safety measures D. Providing social services referral for patient concerns about the cost of the drug - CORRECT ANSWER C. Assessing for drowsiness and implementing safety measures Clonazepam (Klonopin) is a benzodiazepine; because it works on the C N S, it may cause significant drowsiness and dizziness. Safety measures should be implemented to prevent falls and injury. Options 1, 2, and 4 are incorrect. Benzodiazepines may cause hepatotoxicity in patients with existing hepatic insufficiency and may be needed for long-term monitoring. This drug was prescribed after a health care provider's assessment and is currently given to treat a potential short-term condition. The drug should not cause dehydration and is available in generic form. If cost is a concern, social service aid may be needed, but the primary concern for the nurse is safety. A female patient is prescribed dantrolene (Dantrium) for painful muscle spasms associated with multiple sclerosis. The nurse is writing the discharge plan for the patient and will include which of the following teaching points? (Select all that apply.) A. If muscle spasms are severe, supplement the medication with hot baths or showers three times per day. B. Inform the health care provider if she is taking estrogen products. C. Sip water, ice, or hard candy to relieve dry mouth. D. Return periodically for required laboratory work. E. Obtain at least 20 minutes of sun exposure per day to boost vitamin D levels. - CORRECT ANSWER B. Inform the health care provider if she is taking estrogen products. C. Sip water, ice, or hard candy to relieve dry mouth. D. Return periodically for required laboratory work. Dantrolene (Dantrium) may cause hepatotoxicity with the greatest risk occurring for women over age 35, and periodic laboratory tests will be required for monitoring. Estrogen taken concurrently with dantrolene may increase this risk. The drug may cause dry mouth and sucking on hard candy, sucking ice chips, or sipping water may help relieve the dryness. Options 1 and 5 are incorrect. Dantrolene may cause erratic blood pressure, including hypotension, and hot baths or showers cause vasodilation, increasing the risk for syncope and falls. The drug may cause photosensitivity and direct exposure to the sun should be avoided. A patient who has been prescribed baclofen (Lioresal) returns to the health care provider after a week of drug therapy, complaining of continued muscle spasms of the lower back. What further assessment data will the nurse gather? A. Whether the patient has been taking the medication consistently or only when the pain is severe B. Whether the patient has been consuming alcohol during this time C. Whether the patient has increased the dosage without consulting the health care provider D. Whether the patient's log of symptoms indicates that the patient is telling the truth - CORRECT ANSWER A. Whether the patient has been taking the medication consistently or only when the pain is severe Muscle relaxers such as baclofen (Lioresal) work best when taken consistently and not prn. Noting consistency of dosing helps to determine the appropriateness of dose, frequency, and drug effects. Options 2, 3, and 4 are incorrect. Consumption of alcohol or increasing the dose of muscle relaxers will increase the risk of sedation and drowsiness. The patient's log of symptoms and drug dose and frequency may assist the provider in determining the therapeutic outcome of the medication. The patient's report of pain or continued spasms should be considered an accurate account. Which of the following patient statements indicates that the levodopa/carbidopa (Sinemet) is effective? 1. "I'm sleeping a lot more, especially during the day." 2. "My appetite has improved." 3. "I'm able to shower by myself." 4. "My skin doesn't itch anymore." - CORRECT ANSWER Answer: 3 Rationale: Becoming more independent in ADLs shows an improvement in physical abilities. Options 1, 2, and 4 are incorrect. Drowsiness is a common adverse effect of medications for PD. Anorexia or loss of appetite is also a common adverse effect and skin itching is not related to medication use. The patient asks what can be expected from the levodopa/carbidopa (Sinemet) he is taking for treatment of Parkinson's Disease. What is the best response by the nurse? 1. "A cure can be expected within 6 months." 2. "Symptoms can be reduced and the ability to perform ADLs can be improved." 3. "Disease progression will be stopped." 4. "Extrapyramidal symptoms will be prevented." - CORRECT ANSWER Answer: 2 Rationale: Pharmacotherapy does not cure or stop the disease process but does improve the patient's ability to perform ADLs such as eating, bathing, and walking. Options 1, 3, and 4 are incorrect. Drug therapy for PD does not cure or halt progression of the disease. Depending on the drug therapy, EPS may be an adverse effect. Levodopa is prescribed for a patient with Parkinson's disease. At discharge, which of the following teaching points should the nurse include? 1. Monitor blood pressure every 2 hours for the first 2 weeks. 2. Report the development of diarrhea. 3. T